1. Case 1 – I may have noticed a lump in my scrotum

2. ‘I have noticed a lump in my scrotum. Have I got cancer?’
Tom is a 28-year old male who presents with a swelling in the right testicle. He first became aware of the lesion a couple of weeks ago when he was playing with his 18-month old daughter who accidentally head-butted him. He has not felt any pain in the testicle. However, on closer questioning he says that he has noticed a dragging/ heavy sensation in the scrotum off and on over the last few months. He had attributed this symptom to the fact that he has recently taken to jogging to work. On examination he is found to have a non-tender, 2-cm rubbery mass at the apex of the right testicle. The lesion is ovoid. The left testicle is of normal size and consistency.

3. V I N D C A T E O
Testicular Lump Ddx
Vascular
Inflammation
Neoplasm
Congenital
Allergic Autoimmune
Trauma
Obstruction
Skin
Carbuncle
Carcinoma
Urticaria
Contusion
Sebaceous cyst
Subcutaneous Tissue
Cellulitis
Direct inguinal hernia
Tunica Vaginalis
Indirect inguinal hernia
Haematocele, haematoma, hydrocoele
Hydrocele
Venous Plexus
Phlebitis
Obstruction from renal carcinoma
Varicocele
Testis
Orchitis
Seminoma
Teratoma
Syphilis
Non seminoma: Embryonal carcinoma, Chorioepithelioma, Yolk sac, teratoma
Mixed germ cell
Non germ cell: sex cord tumours
Hydatid cyst of Morgagni
Epididymis
Bacterial epididymitis
Cyst
Spermatocele
Tuberculosis
Artery
Torsion
Vas Deferens
Secondary to obstruction by carcinoma of prostate
Prostate disease
Lymphatics
Filariasis

4. Probability Dx
Signs & Symptoms: Rubbery consistency, painless lump, dragging sensation for 2 months makes neoplasm or cyst (epididymal cyst, Hydatid cyst of Morgagni) likely.
Age 27 excludes lymphoma, more likely to be seminoma but other types (non-seminoma, mixed germ cell, sex cord tumours and non-germ cell tumours) must be ruled out by biopsy.
Trauma: head butt by daughter raises possibility of trauma causing haematoma, haematocele, hydrocele.
Presence of fever, pain, malaise, nausea with a Hx of unsafe sexual practices, multiple partners, etc. would make bacterial infection more likely. Mumps is most common cause of orchitis – but still need more history.

5. Other Hx
Confirm that the daughter did actually head butt him in the goolies. Did the lump appear soon after?
The lump itself: has it since changed size, consistency
Associated symptoms of malignancy: weight loss, night sweats, metastases: lung (cough, haemoptysis), back pain, enlarged cervical or inguinal nodes
Any symptoms associated with infection: fever, malaise, nausea, penile discharge (puss, blood), dysuria, skin changes, arthropathies
PMH: cryptorchidism, UTI’s, STI’s, mumps, parotid swelling
Social Hx (O/S travel, sexual Hx)
Family Hx: varicose veins (varicocele), cancers

6. Further clinical examination?
Transillumination
Abdominal exam
Lymph nodes
Neuro
Ankle edema
Gynecomastia
Thyroid

7. Investigations? Ultrasound MRI α fetoprotein β hCG LDH Sperm count
AJCC/UICC TNM staging

8. Treatment options? Sperm cryopreservation Radical inguinal orchiectomy
Testicle sparing surgery
Retroperitoneal lymph node dissection
Chemotherapy
Active surveillance
Radiation therapy

9. Sources
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